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MINNESOTA DEPARTMENT OF HFALTN Minnesota Well and Boring ���0�� —� <br /> WE«oR BOR�N��o�AT�oN _ WELL AND BORING SEALING RECORD Sealing No. q i H <br /> Counry Name Minnesota Uni ue Well No. r--- -- <br /> HENNEPIN Minnesota Statutes. Chapter 103� or W-series No. �— � <br /> ti.ew u�x�o�wmwn� <br /> Township Name Townsh�p No. Range No Section No Fraction(sm.-►Iq.) Date Sealed Date Well or Boring Constructetl <br /> ORONO 117 23 17 ��.SE �.NW�,. Wednesday,September 06,2000 <br /> Numencal Street Address or Fhe Number and CRy of Well or Bonng Locahon 55 <br /> 1875 SHADYWOOD ROAD Depth Before Sealing_ __R Original Depth __n <br /> Show exact locafion of K-ell or bonng Sketch map of weli or bonng AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". Iocation, showing property �Single Aywfer ❑ Mulfiaqurter <br /> Gnes,roads, tl buildings. �,,c, <br /> N I WELUBORING iJ Measured ❑ Esumated <br /> g]Water Supply Well ❑Monit.Well <br /> ,`�e ❑ Env.Bore Hole ❑Other _ _30 tt. C� below ❑ above land surtace <br /> W --�- - -i-- --'-- E '--- CASING TYPE�S) <br /> ' � � ' a <br /> � � � Galvanized T&C <br /> -;-- -'-- <br /> _�__ __�__ haus o s�eei ❑ Plastic ❑r�ie ❑ o�ne� <br /> }1 mile p� <br /> ' ' ' ' � o CASING(S) <br /> -�-- -�-- -�-- --i-- <br /> ' a Diameter Depth Set in oversize hole? Annular space initially grouted7 <br /> re <br /> �r mxe� `�I 2 in.irom 0 to 55 tt. ❑ Yes �] No ❑ �es ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME { in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> TILLOTSON,GLEN <br /> Property owner's mailmg address if ditterent ihan well location adtlress indlcated above. in.from to ft. ❑ �es ❑No ❑ �es ❑No ❑ Unknown <br /> 1875 SHADYWOOD ROAD SCREEWOPEN HOLE <br /> ORONO,MN 55391 Screen from 55 to ft Open Hole from ro ft. <br /> OBSTRUCTIONS <br />. . WELL OWNER'S NAME �] Fods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Weil owners mailing address if difierent than properry owner's address inGicated above. Type of Obstruc�ions(Describe) REfT10VeCJ 4Z'X 1.25"Drop Pipe&Jet Packer... <br /> Obsiructions removed? �Yes ❑ No Describe <br /> PUMP <br /> TYPe Deep Well Jet Pump... <br /> GEOL061CAL MATERIAL COLOR HARDNESS OF FROM 70 � Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> It rat krawn,indicate estimated formatbn log from nearDy well or bonng. �METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> TJ No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to n. ❑ Pertorated ❑ Removed <br /> in.from to h. ❑ PeAorated ❑ Removed <br /> Type of perforator <br /> ❑ otner <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=SO lbs.) <br /> Neat Cmt 3 3.5 0.0004 <br /> Grouting Material from to it. yarOs bags <br /> Enviroplug 3•5 55 0.0412 <br /> from to R. yards bags <br /> � <br /> from to ft. yerds begs <br /> trom to_ fl. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Well Located In Backfilled Well Pit On West Side Of House... oine�unseaied and u�used Weu or bor�ny on Property? ❑ves �]No How many? <br /> � � '� LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> Measured From Grade Level... <br /> � This well or boring was sealed in accordance wiM Minnesota Fules,Chapter 4725. The information contained in Mis repoR is <br /> true to Ihe best of my knowleAge. <br /> Malenke Water 763.493.3650 27600 <br /> i�Y �}f V a'i s_. ..,� Conhactor Business Name J License a Registretlon I'io. <br /> / <br /> Myron Malenke ,,�`, ` �;:•- ! ,, September 06, 2000 <br /> 17 117' 23 24 ���2 Authonzed Representative Signature Dete <br />.. I_.1�1`�a:. ,,,�c.�y p�,k u A ��� j� Name o/Person Sealing Well or Bonng <br /> r� 1 t� <br />